“Study participants whose pain was managed during labor had a 14-percent rate of depression at six weeks after delivery, compared to a nearly 35-percent rate of depression for those who did not have the pain relief. The study also found that women who attended childbirth classes during pregnancy and those who breastfed after labor lowered their risk of postpartum depression. Breastfeeding was more common in the group who had an epidural for pain (70 percent) compared to those who did not (50 percent).

The study, which will be published in the August issue of Anesthesia & Analgesia, involved 214 women, half of whom were given an epidural to reduce their pain during the vaginal delivery of their child. The other 107 participants were not given any pain medication during delivery. The mental statuses of all study participants were examined three days after delivery and again six weeks after delivery using an established postnatal depression scale.”

What do you think of this study?

I think there are so many factors that can play into PPD that it would be hard to prove that the epidural is the main factor. I was surprised that the numbers for BFing were higher for those that had an epidural. Still, interesting study. I had an epidural and LOVED it.

After reading the abstract, I’d like to point out a couple of things about this study that need to be taken into consideration:

– it appears that the research was conducted in China, presumably with Chinese participants.

– the participants were enrolled in the study while they were pregnant, and it appears that half were assigned to the epidural group and the other half to the no-pain-relief group. I don’t see anything about whether the participants got to choose which group they were in, or whether it was assigned at random.

Either way, it poses a problem for the research conclusions: if the groups were self-selected, that would mean that there could be inherent differences in the groups (i.e. type of personality, underlying risk of depression, etc.), so the results might well be due to that and not cause-and-effect because of the epi. If the groups were assigned at random, then it means that the no-pain-relief group was basically denied the option of an epi (or anything else, from the looks of it) even if they wanted one. If that’s the case, no wonder their PPD is higher! Of *course* women will be at higher risk of PPD if they want pain relief in labor and are denied it. We also don’t know if the no-pain-relief group received appropriate labor support, if they were free to move around during labor, use water, etc., or if they were stuck in bed on their backs with their legs in the air and strapped to monitors.

This type of study would basically be impossible to do in the US (or at the least very difficult) for ethical reasons. If you try to assign groups like this beforehand, you might have a lot of women end up switching groups (because labor is unpredictable – some women who don’t plan to use pain relief end up wanting it, and some wome who expect to want it end up going without, because their labor is so quick or because they find they don’t actually need it after all). If the groups are involuntary and pain relief is forced on or withheld from someone who wants the opposite, you have an unethical study design. If groups are self-selected, you have the aforementioned problem of group differences.

I suspect that, across the board, women being able to labor the way they prefer, whether that be with or without an epidural, is probably associated with better outcomes vis-a-vis PPD, and I’m not at all surprised that the study found an association between risk of PPD and what looks like a cohort of women who were denied access to pain relief during labor because of the study design, regardless of what they wanted in the moment.

Just read the study itself, and I should clarify some things now that I have more context:

It looks like the participants opted in to the study (with informed consent) when they showed up at the hospital in labor, and they chose which group they wanted to be in. (So, that’s good – nobody was forced to be in either group against their will.) The study doesn’t say, though, what happened with women who opted for the no-pain-relief group at the beginning of labor and then changed their minds partway through – that still concerns me. A woman who changes her mind and decides she does want pain relief, but can’t get it because of the group she opted into, might well be upset with those circumstances and end up at increased risk for PPD.

– The way the numbers worked out in this study seems really weird to me. Of the eligible pool of participants (517 women), almost exactly half (258) enrolled in the study and half (259) did not. Of the women who completed it, the two groups were again exactly 50/50 (214 total; 107 in each group). Those numbers are too small, first of all, to draw broad conclusions, but it’s also just strange that everything was so perfectly balanced like that. I also wonder, looking at the women who didn’t complete the full study and were excluded from the final analysis: a bunch of the reasons listed might well be associated with PPD (in other words, PPD might have been part of why they didn’t complete the study) and so leaving them out could really be throwing the numbers off, especially with such small groups.

– PPD is also known to be associated with cultural practices (such as the kind of support provided to mothers during recovery, etc.), which are probably very different between the US and China, but the study doesn’t really go into any of that.

– a larger number of the no-pain-relief group (62% vs. 55%) reported being worried about giving birth. In a study with such small numbers, that could make a significant difference to the outcome, since anxiety/apprehension about birth might be an indicator of PPD risk.

– By far, though, the biggest question mark for me is that the no-pain-relief group had a WAY higher rate of cesarean delivery (36% vs. 15% for the epidural group). These were all unplanned C-sections, since planned C-sections were excluded from the study. The conclusion acknowledges that this is an unusual outcome. The question remains, though: doesn’t it seem likely that the no-pain-relief group’s higher PPD might be linked to the much higher C-section rate?